Provider First Line Business Practice Location Address:
3929 LA MESA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHASTA LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96019-9210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-510-2448
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2026